Getting insurance to cover GLP-1 medications can feel like a full-time job. Prior authorizations, step therapy requirements, denials, appeals—the process is frustrating by design. But it's winnable. With the right approach, many patients who are initially denied eventually get coverage.
This guide walks through the process: what insurers require, how to meet those requirements, and what to do when they say no.
The Coverage Landscape
Insurance coverage for GLP-1 weight loss medications varies dramatically:
- Medicare: Generally does NOT cover weight loss medications (though covers for diabetes)
- Medicaid: Varies by state; some cover, many don't
- Employer plans: Highly variable; trend toward coverage is increasing
- ACA marketplace: Often excludes weight loss drugs unless state mandates coverage
The first step: check whether your plan covers GLP-1 medications at all. Call your insurance or check your formulary. If weight loss drugs are explicitly excluded, prior authorization won't help—you'll need alternative strategies.
Standard Prior Authorization Requirements
For plans that do cover GLP-1 medications, prior authorization typically requires:
Medical Criteria
- BMI ≥30 (obesity), OR
- BMI ≥27 with at least one weight-related comorbidity (diabetes, hypertension, sleep apnea, etc.)
- Documentation of weight-related condition(s)
Prior Attempts
- 3-6 months of documented supervised weight loss attempt
- May require specific program (dietitian, physician-supervised)
- Documentation of calories, exercise, weight tracking
Step Therapy
Some insurers require trying (and failing) cheaper medications first:
- Phentermine
- Topiramate
- Naltrexone-bupropion (Contrave)
- Orlistat (Alli/Xenical)
Provider Requirements
- Prescription from specific provider types (sometimes excludes telehealth)
- May require endocrinologist, bariatric specialist, or specific certification
Preparing a Strong Prior Authorization
Document Everything
Gather records of your weight history, previous weight loss attempts (even informal ones), and all weight-related health conditions. The more documentation, the better.
Get Comorbidities Diagnosed
If you have sleep apnea, get a formal diagnosis. If your blood pressure is borderline, have it documented. Comorbidities strengthen your case and may qualify you at lower BMI.
Complete Required Lifestyle Programs
If your insurer requires supervised weight loss attempts, do them properly and get documentation. Some telehealth providers include this as part of their program.
Work With Your Provider
Ensure your provider writes a detailed letter of medical necessity explaining why this specific medication is needed and why alternatives aren't appropriate.
Use Clinical Trial Data
Reference specific outcomes: 15-20% weight loss, cardiovascular risk reduction, diabetes prevention. Make the case that this is evidence-based medicine.
When You're Denied: The Appeal Process
Initial denial isn't the end. The data on appeals is encouraging:
Appeal Success Rates
The most important statistic: 85% of denied patients never appeal. Insurers count on this. Simply filing an appeal puts you ahead of most people.
Internal Appeal
- Usually must file within 30-180 days of denial
- Include additional documentation addressing specific denial reasons
- Request peer-to-peer review (your doctor speaks directly with insurer's medical director)
- Cite clinical guidelines and evidence
External Appeal
If internal appeal fails, you have the right to external review by an independent third party. This is often more favorable than internal review.
Tips for Successful Appeals
- Address the specific reason for denial directly
- Include new information not in the original request
- Get a detailed letter from your provider explaining medical necessity
- Reference FDA approval and clinical trial data
- Document failed alternatives if step therapy was required
- Meet deadlines—late appeals are automatically rejected
The Diabetes Route
A commonly used strategy: if you have type 2 diabetes or prediabetes, GLP-1 medications may be covered for diabetes even when excluded for weight loss.
- Ozempic (semaglutide 1mg) is a diabetes drug
- Mounjaro (tirzepatide) is approved for diabetes
- Coverage is often better with diabetes diagnosis
If you have prediabetes (A1C 5.7-6.4%), some providers will prescribe Ozempic or Mounjaro for diabetes prevention, potentially with better coverage than weight loss indications.
Important: This isn't about gaming the system—if you have obesity, you likely have metabolic dysfunction even if it hasn't crossed the diabetes threshold. The medication is treating your metabolic condition either way.
Manufacturer Programs
Both Novo Nordisk and Eli Lilly offer programs that can dramatically reduce costs:
Novo Nordisk (Wegovy/Ozempic)
| Program | Details |
|---|---|
| Savings Card (with coverage) | Pay as low as $25/month; max savings ~$100/month |
| NovoCare Self-Pay | $499/month without insurance |
| Oral Wegovy | $149-299/month |
| Patient Assistance (PAP) | Free medication for income ≤200-400% FPL |
Eli Lilly (Zepbound/Mounjaro)
| Program | Details |
|---|---|
| Savings Card (with coverage) | Pay as low as $25/month |
| LillyDirect (vials) | $299/mo (2.5mg), $399/mo (5mg), $449/mo (7.5-15mg) |
| Lilly Cares (PAP) | Free medication for income ≤500% FPL |
Key point about LillyDirect: it's available to anyone regardless of insurance status, including those with Medicare or Medicaid. The vials require you to draw your own injections (or your provider can show you how), but the cost savings are substantial.
Alternative Access Routes
If insurance won't cover and manufacturer programs don't work:
Telehealth Providers
Many telehealth platforms offer GLP-1 medications at competitive cash prices with included consultation. They often handle prior authorizations and can help navigate coverage.
Compounding (Where Available)
Tirzepatide can still be compounded since it remains in shortage. Compounded medications are typically $200-400/month. Note: compounded semaglutide is now restricted since the shortage resolved in February 2025.
International Options
Some patients purchase medications from international pharmacies at dramatically lower prices. US prices are roughly 10x higher than many countries. This involves legal gray areas and requires careful vetting of pharmacies.
Flexible Spending/HSA
If you have an FSA or HSA, GLP-1 medications (with prescription) are generally eligible expenses, reducing effective cost through tax savings.
What to Say to Your Insurer
When calling your insurance company:
- "I'd like to understand the specific criteria for prior authorization for [medication name]."
- "What documentation is required?"
- "Is there step therapy required? What alternatives must be tried first?"
- "If I'm denied, what is the appeal process and timeline?"
- "Is there a peer-to-peer review option?"
Document every call: date, time, representative name, and what was said. This creates a record if disputes arise.
The Long Game
Insurance coverage for GLP-1 medications is evolving rapidly. The trends:
- More employers adding coverage as they recognize cost savings from preventing obesity-related diseases
- Some states mandating coverage
- Medicare may eventually cover weight loss medications (legislative efforts ongoing)
- Prices likely to decrease as competition increases and generics eventually arrive
If you can't get coverage now, the landscape may improve. In the meantime, manufacturer programs and alternative routes may bridge the gap.
Key Takeaways
- Check your formulary first—know if coverage is even possible
- Prepare thoroughly for prior authorization with complete documentation
- Always appeal denials—success rates are meaningful and most people don't bother
- Use manufacturer programs—significant savings available for most patients
- Consider alternative routes if traditional coverage fails
- Be persistent—the system is designed to discourage you, but coverage is often achievable
Need Help Navigating Coverage?
Many telehealth providers assist with prior authorizations and insurance navigation.
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